Basic Information
| Provider Information | |||||||||
| NPI: | 1366606923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFE | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1408 EAST ST | ||||||||
| Address2: | |||||||||
| City: | IOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667494402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203653115 | ||||||||
| FaxNumber: | 6203657717 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 E TAMPA ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658061131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178511551 | ||||||||
| FaxNumber: | 4178328275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2008 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 05-34960 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2017016279 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2017016279 | 01 | MO | MISSOURI PROFESSIONAL LICENSE | OTHER |